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Dallas Denny

Three Levels of Transgender Health Care

The 3rd New England Transgender Health Conference

By Dallas Denny




Health care for transgendered and transexual people is a problem on a number of levels. I will mention three. On one level, there is the problem of obtaining and monitoring the medical treatment necessary to change the body's primary and secondary sex characteristics. On a second level, there are the same ongoing general health care concerns that concern nontrans people, and additional concerns associated with body-transforming medical treatments. And on the third and perhaps most important level, there are serious health risks associated with reduced socioeconomic status caused by societal rejection and inability to find employment.

Level One: Access to Body-Changing Medical Technology

Obtaining access to hormones, chest surgery, and sex reassignment surgery is a challenge, as mental health professionals serve as watchdogs to sex reassignment technologies. This psychiatric gatekeeping is specific to transpeople, and is not required of those who alter their bodies in other, equally significant ways. For instance, once can have one's body-- including one's genitals-- extensively pierced or tattooed without presenting a therapist letter to the piercer or tattooer; or one can have race, age, and gender-altering facial plastic surgery of the Michael Jackson type without having to first see a therapist.

The professional standards of care which encourage psychiatric gatekeeping assume that transpeople have geographic and financial access to competent and compassionate mental health professionals. This is rarely the case. Transpeople in rural areas and those in urban areas with limited funds have extreme difficulty getting authorization letters. It often becomes less inconvenient to obtain hormones by extralegal means or seek out surgeons outside the U.S., despite the extreme health risks of doing so.

The standards of care are vague. They do not lay out clear treatment guidelines. They leave much unaddressed, and much of what they do say is open to interpretation. They allow arbitrary decision-making by therapists and gives therapists financial motivations for keeping their transexual and transgendered clients on the hook for as long as possible at $125 per hour. This dynamic leads to power games which can have tragic consequences, as was recently the case in San Diego, when a therapist was shot to death by her transsexual client, who then turned her pistol on herself. The standards of care are unbalanced. They are based on a psychomedical model of transsexualism that we are increasingly coming to understand has led to presumptions of impotence of transgendered and transexual people. Their language clearly shows this. They are based on clinical judgement that is often rooted in just those types of erroneous suppositions. They are not data-based. There is no empirical evidence whatsoever that those who follow the standards do better than those who do not. We-- many of us, anyway, only think they do. Professionals are restricting the personal freedom, the right to their bodies, of an entire class of people out of do-good motives, but without taking the time and trouble to make sure they are doing the right thing. "We're doctors. We're here to help you."

There is also a problem with lack of health insurance for this type of treatment. Most health policies specifically exclude transsexualism from coverage.

Level Two: Access to Routine Health Care

Obtaining routine health care can be a problem for transexual and transgendered people, who often find that medical treatment is denied them simply because of their status. A transperson who requests counseling for depression, for instance, may find it denied under medical insurance on the grounds that the policy excludes treatment for gender dysphoria. Most often, the individual is unable to obtain treatment because a transphobic practitioner finds transpeople make him or her uncomfortable or flatly refuses to see them.

Even when medical treatment is available, transpeople may not have their health care needs seen to. They may be uncomfortable with showing up at the doctor's office with an androgynous physical presentation or with physical characteristics which run counter to their apparent sex. They may feel uncomfortable with their transgender or transexual status being known.

Such avoidance of health care is not limited to those who are pre-transition or in transition; those who are post-transition and even postoperative may stay away from the doctor because they do not want their former gender status to be revealed.

There is a problem with health insurance coverage at this level, also. Transgendered and transexual people who are insured can find that needed treatments are denied even though they are not directly or even indirectly related to their gender issues. At special risk is any type of mental health treatment.

Level Three: Health Problems Associated with Diminished Income and Alternate Lifestyles

Transexual and transgendered people often find themselves at a lifelong financial disadvantage. Androgynous physical characteristics, masculine behavior in females or feminine behavior in males, or crossdressing from an early age often leads to stigmatization and rejection. Discrimination can make it difficult or impossible to pursue educational opportunities or to find employment. Over time, the individual becomes progressively less suitable for the job market because there has been no opportunity for training or education. Transpeople are often forced into careers such as sex work or drug dealing, which are associated with a variety of health risks, including HIV, sexually transmitted diseases, hepatitis, drug abuse, and mental illness. There is great risk of being attacked or murdered, and scrutiny by the police can lead to arrest and incarceration, which present particular health risks for transpeople. Disadvantaged transpeople have difficulty affording and see little sense in hiring expensive gatekeepers to authorize medical treatments. Under such conditions, street hormones, silicone injections, and backroom surgery seem especially attractive.

In the face of such serious health problems, disadvantaged transpeople are in real trouble. They have no resources to pay for their treatment, they do not have insurance, and they are often excluded from public programs because of their gender issues. They may be ridiculed or abused at hospitals, housed inappropriately with members of their natal gender, or simply refused treatment. Hospices and shelters are especially bad about this.

Another disadvantaged population is those who live in rural areas. In cities like Philadelphia, where there are lots of services, it's easy to forget that there seem to be no sympathetic health care providers in either of the Dakotas. I once got a hot-line call from an individual in Newfoundland. The nearest source of support was 1500 miles away, in Toronto. In some countries, the governments are apathetic towards transgendered and transexual people. In other countries, they are actively hostile. In Argentina and Turkey, for instance, transpeople are routinely imprisoned, tortured, and murdered by the police. In our own country, we are fighting a cultural war that will determine whether gay, lesbian, and bisexual Americans and transgendered and transsexual Americans will be able to live in peace and dignity.

What Is to Be Done?

I have identified a number of areas that must be addressed. I'm sure there are more. Those I have recognized include:

  1. More on-site information and support for disadvantaged transpeople. There is a need to develop programs which reach transfolk on the streets, and support the transgender support programs which are already in existence. We also need to cross-train the staff of shelters, GLBT organizations, HIV service agencies, and other relief organizations so they will not be afraid or unresponsive when transpeople apply to them for services.
  2. Make health care affordable. Let's start with insurance reform. Insurance companies must be educated, made to understand that the assumptions they have about transpeople are not necessarily true, and lobbied to change their exclusionary policies. We must convince the Health Care Financing Administration that sex reassignment surgery is not an experimental procedure, but a routine one which proven health benefits.
  3. Let's reform professional standards. Current standards of care give too much power to the caregiver. This imbalance of power must be respectfully renegotiated with the understanding that transpeople are not de facto mentally ill, and that it is unethical to limit access to treatment unless there are empirical data which clearly show the benefits of doing so (such data are currently lacking). Professionals much also understand that it is unethical to force transpeople to conform to their notions of masculinity or femininity, pressure transpeople into requesting surgery as a condition for obtaining hormones, or withhold treatment from transpeople because they possess or lack certain physical characteristics (i.e., do not "pass").
  4. Let's educate professionals. Medical and mental health professionals must be educated about the needs of transgendered and transexual people. It is important to get information into college textbooks and make presentations at colleges and universities, and to educate via in-services, workshops, and journal articles those professionals who are no longer in school. Especially needed are articles which provide alternative models to the psychomedical model of transsexualism.
  5. Comprehensive health care. There is a great need for programs which address the overall health needs of transexual and transgendered people. This method provides advantages not possible with "a la carte" approaches, in which one goes here for hormones, there for control of diabetes, and yonder for sex reassignment surgery. This comprehensive approach ensures that health care is coordinated and that health concerns do not slip through the cracks.
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